SSA-1399 Auto Pay Request Form

Form Approved
OMB No. 0960-0644

SOCIAL SECURITY ADMINISTRATION

Universal Auto Pay (UAP) Request Form
Note: Certain requirements for eligibility apply. In order for your Employment Network (EN) to qualify
for Universal Auto Pay (UAP), you must meet the following criteria:
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Have a current EN agreement with Social Security in good standing
Have at least five Tickets assigned

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Have no overpayments or are able to pay back current overpayments

Please fill in the following in order to enroll in Unversal Auto Pay for ALL of your assigned
Ticket Holders.
EN Name:

DUNS Number:

Your Name:

Title:

By checking the box below, you are signing up to receive the following:
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Quarterly Earnings alert for all your Ticket Holders to indicate who is working
above Trial Work Level (TWL)
Automated payments with the three month delay for Outcomes 1-12

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Automated payments the following month for Outcomes 13 and beyond

Please place ALL of our assigned Ticket Holders on UAP.
By signing below, you as the EN agree to repay any payment(s) received or allow the amount to be deducted
from future payment(s) if it is determined at a later date that you were not entitled to the payment(s).

I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that
anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes
someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

Signature:

Date

Please fax this form to Operations Support Manager (OSM) at 703.893.4020.

Form SSA-1399 (02-2013)

Page 1

Privacy Act Statement
Collection and Use of Personal Information

Section 1148, of the Social Security Act, as amended, authorizes us to collect this information. The information
is needed to permit the Social Security Administration (SSA) to monitor the progress of a participant in the
Ticket to Work and Self Sufficiency Program. The information you furnish on this form is voluntary. However,
failure to provide all or part of the information requested on this form will prevent assignment of your Ticket to
Work to your selected provider of services.
We rarely use the information you supply for any purpose other than for monitoring the progress of a participant
in the Ticket to Work and Self Sufficiency Program. However, we may use it for the administration and integrity
of Social Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to:
(1)

To enable a third party or an agency to assist Social Security in establishing rights
to Social Security benefits and/or coverage;

(2)

To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veteran Affairs);

(3)

To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and

(4)

To facilitate statistical research, audit or investigative activities necessary to assure
the integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, state or local government agencies. Information from these
matching programs can be used to establish or verify a person's eligibility for Federally funded and administered
benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record Notices 60-0295 and
60-0300. The notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it will
take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO: OPERATIONS SUPPORT MANAGER (OSM) TICKET TO WORK, PO BOX 1433,
ALEXANDRIA, VA 22313 OR FAX TO 703-893-4149. You may send comments on our time estimate above
to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed form.

Form SSA-1399 (02-2013)

Page 2

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:

Privacy Act Statement
Collection and Use of Personal Information

Section 1148 of the Social Security Act authorizes us to collect this information. We will
use the information to enroll your Employment Network (EN) in Universal Auto Pay
(UAP).
Furnishing us this information is voluntary; however, failing to provide all or part of the
information will prevent us from enrolling your EN in UAP.
We rarely use the information you supply for any purpose other than what we state
above, however, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to
ensure the integrity and improvement of our programs (e.g., to the Bureau of
the Census and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice, 60-0295, entitled Ticket-to-Work
and Self-Sufficiency Program Payment Database, and 60-0300, entitled Ticket-to-Work
Program Manager (PM) Management Information System. Additional information about
this and other system of records notices and our programs are available from our
Internet website at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for federally funded or administered benefit
programs and for repayment of incorrect payments or delinquent debts under these
programs.

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Form SSA-1399 (02-2013)